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THEDACARE PHARMACY - WAUTOMA
CAH521355-00 ThedaCare Medical Center Berlin, Inc.
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Covered Entity Details
Entity Name
ThedaCare Medical Center Berlin, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521355-00
Entity Address
225 MEMORIAL DRIVE
BERLIN, WI 54923
Medicare Provider Number
521355
Participating Start Date
7/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
THEDACARE PHARMACY - WAUTOMA
Pharmacy Address
N2934 HWY 22 N
WAUTOMA, WI 54982-0645
Pharmacy Comments
Contract Details
Approval Date
11/17/2011
Contract Begin Date
11/17/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/12/2017
Ownership change
Contacts
Covered Entity Signing Official
Thomas P. Krystowiak, Chief Financial Officer
(920) 361-1313
Contract Pharmacy Representative
Thomas P. Krystowiak, Chief Financial Officer
(920) 361-1313
Signed By Date
11/10/2011
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